Should I give my baby a dummy/pacifier?
When I chose to write this blog about dummies/pacifiers I was surprised to almost
disappear down a research rabbit hole! This article considers the pros and cons of
dummy use according to the available evidence, and I found there is a LOT of
research to consider. Dummies or pacifiers have been used in various forms to settle
infants for centuries. The dummies currently available are similar to those that have
been available for decades.
Suckling without fluid transfer is called non-nutritive sucking (NNS). Non-nutritive
sucking is considered a normal part of fetal and neonatal development. As early as
13–16 weeks gestation the fetus has started sucking and swallowing movements.
These fetal movements are considered to be important precursors for the lifesustaining requirements of breathing and swallowing. Non-nutritive sucking is intimately related with the rooting reflex, which is the movement of the infant’s head and tongue towards an object touching its cheek. The object is usually the mother’s breast, but may also be a finger (parent’s or baby’s own) or a pacifier.
Non-nutritive sucking in infants is nearly universal and is considered normal. A
variety of non-nutritive sucking habits exist, but thumb, digit and pacifier sucking are
most common. Pacifiers/dummies encourage NNS – the immature front-back action
of suckling.1
Some newborn babies demonstrate their own version of NNS by sucking their
tongues or lips in utero. This habit established before birth can sometimes interfere
with a baby’s ability to latch and effectively suckle at the breast, temporarily. “Suck
training” on a parents’ finger can coaxe the babies tongue position forward, and
when rewarded with small amounts of colostrum/breastmilk the baby discovers a
more appropriate way of sucking which is more rewarding.
Concerns have been raised about the use of dummies and teats during breast
feeding. Historically, the WHO Baby Friendly Health Initiative (BFHI) have
strongly advised against the use of pacifiers and teats because it interferes with
breastfeeding and significantly decreases duration of lactation. (BFHI Step 9).
This advice was modified in 2018 in response to evidence-based research, to
read: “Counsel mothers on the use and risks of feeding bottles, teats and
pacifiers”.
The impact of pacifier use on breastfeeding has been the subject of numerous
studies. The objective of one large study conducted in Argentina was to
evaluate whether the recommendation to offer a pacifier once lactation was well
established reduced the prevalence or duration of lactation. The population
included 1023 mothers who were highly motivated to breastfeed whose
newborns regained birth weight by 15 days. Mothers were randomly assigned to
one of two groups: offering a pacifier, and not offering pacifier. The offering
group received a package containing six silicone pacifiers, supplied by MAM
Babyartikel Gesmbh and not sold in Argentina. The study demonstrated that
when mothers are determined to breastfeed for more than three months
and they are successfully breastfeeding at two weeks the advice to use or not to
use a pacifier does not affect breastfeeding. Results from four other randomised
controlled trials also revealed no difference in breastfeeding outcomes in
different types of pacifier interventions 2
There is little evidence that dummy use adversely influences breast feeding
development in pre-term babies. The literature indicates benefits of using nonnutritive sucking with infants who are premature. Non-nutritive sucking benefits preterm babies in terms of successful transition to oral feeding and quicker discharge home. Note – this does not necessarily refer to breastfeeding, and may in fact refer to oral feeding via bottle and teat 3.
Providing NNS using a pacifier has shown to reduce babies’ distress during painful
medical procedures. Likewise, a landmark study “Pacifiers and Sudden Infant Death Syndrome” carried out in 1993 first showed the connection between SIDS and pacifiers, specifically, the reduced risk of SIDS if a pacifier had been used.
This was supported by eleven further case-control studies which compare
a treatment or intervention group with a group which have not received the
treatment. These studies showed the risk of SIDS was reduced by
approximately 50% if a pacifier was used. Additional meta-analyses (which
analyse the results of multiple studies) also reached the same conclusion.
Interestingly, the use of a pacifier at the onset of sleep appeared protective,
even if the pacifier falls out of the mouth after the infant falls asleep.
How are pacifiers protective in the sleep environment?
One recent study suggests that pacifiers lower the auditory arousal threshold,
and they may provide a mechanical barrier to rolling over into the prone
position. Sucking on a pacifier keeps the tongue forward maintaining upper
airway patency. An infant who is soothed by a pacifier may not move as often
during sleep, thus limiting the chance of becoming covered by blankets. It has
also been suggested that pacifier use could lead to slight carbon dioxide
retention and increase the respiratory drive4
So, the humble dummy might not be the demonic tool some clinicians warn parents
must avoid. Common sense should have a place here, amongst the auspicious
research. Like any tool, it is how it is used which determines its effectiveness, or
otherwise. Dummies CAN be misused, for example, as a means of making baby
wait longer between feeds aka “stretching feed times”. This is never appropriate.
Regardless of whether baby is breastfed or bottle fed, babies should be fed when
they indicate they are hungry.
Dummy use may suppress hunger cues, or parents may miss noticing baby’s cues
which can lead to less frequent feedings, insufficient weight gains and reduced
actation in breastfeeding mothers. Breastfeeds may be cut short if the mother does
not permit a period of non-nutritive suckling towards the end of a feed phase, and
gives baby a dummy instead. This can result in baby failing to cue for further phases
of the feed which could compliment the initial breastfeed phase by providing an
opportunity to transfer some of the higher-fat, slower flowing milk which completes
the breastfeed.
Missing or misunderstanding hunger cues can happen more easily in the first few
weeks of baby’s life. These early days of apparently endless feeds and nappy
changes are crucial for baby’s wellbeing, as well as stimulating the initiation and
establishment of a mother’s breast milk supply. For this reason avoiding dummy use
in the first few weeks is usually recommended by health professionals.
Pacifier use has been implicated as potentially contributing to increased risk of ear
infections, particularly in older infants. However, other studies have not found
evidence to attribute direct causality, with socio-demographic characteristics
influencing results 5
Which leads to the next question: Which dummy shape is the best?
The quest to answer this led me even deeper down the research rabbit hole. A
venture to internet shopping revealed a dazzling range of dummy choices. To keep
it simple, there are 4 basic shapes on offer – orthodontic, cylindrical, butterfly and
cherry shapes.
This is where the research got heavy. Really, heavy. The pro-orthodontic shape
recommendations are underpinned by elaborate modelling experiments which
calculate the forces exerted by various shaped dummies inside a simulated infant
oral cavity. This research was conducted by orthodontic clinicians investigating the
role of the pacifier as a potential cause of dental malocclusions. Their findings
indicate the orthodontic shape is less likely to compromise development of the midpalatine suture, and maintains support of the transversal diameters of the premaxilla, reducing the risk of open bite.6 That’s my simplified translation!
However, nowhere in this extensive body of complicated dental research did I see
any reference to pacifier/dummy use and breastfeeding efficacy or support – no
human babies were used (or harmed) during this research. Additionally, when I
viewed the full text version I noted “Competing interests” are recorded, relating to
several US patents (Smilo and Tomy). Keeping this information in context, the
effects of pacifier use on infants’ intra-oral development is significantly determined by
the duration of its use. Most commonly parents are advised to eliminate use of
dummies/pacifiers by 2 years of age to avoid potential detrimental effects on the
child’s primary dentition (baby teeth).
Breastfeeding is associated with optimal oral and craniofacial development in
infants7 The round “cherry” shaped dummy is most commonly recommended by
breastfeeding clinicians, as it most closely resembles the (ideal) shape of a human
nipple. The rounded shape encourages “cupping” of the sides of the tongue, which is
consistent with the tongue action during suckling at the breast. During swallowing,
the tongue naturally moves towards the back of the throat, and a rounded “cherry”
shape enables a similar action during non-nutritive sucking. Conversely, some
“orthodontic” shaped dummies can encourage a humping of the tongue and reverse
tongue movement towards the front of the mouth. This tongue action is incompatible
with breastfeeding.
The cylindrical shaped dummy is commonly used in neonatal settings, often
introduced to counteract pain responses during medical interventions. The small
diameter of the bulb tends to suit small and premature baby’s mouths.
I have not been able to find any research which demonstrates the rationale for the
flat peg-shaped bulb of the Butterfly dummy. Dr Browns butterfly pacifier is marketed
as being developed by a pediatric dentist to help prevent dental issues. The
contoured shape of the shield curves away from baby’s nose and cheeks.
Regardless of the scientific research and artificial modelling, the method of feeding
or the parents’ pre-baby plans – ultimately the baby decides. Many babies flat out
reject all types of dummies. Trial and error may result in the baby declaring which
dummy is acceptable, following multiple dummy purchases.
Here’s what I have to say about using dummies in my book “NewBaby101 – A
Midwife’s Guide for New Parents” Dummies or pacifiers and bottle feeding with a
teat are not recommended for breastfeeding babies because they alter the way baby
uses his tongue, which can confound baby’s tongue action when breastfeeding. If
you choose to have a dummy on hand, choose one with a round bulb end (cherry
style). The “orthodontic” or flat/wedge shaped dummies encourage a sucking action
which may encourage the back of the tongue “hump” which can be detrimental to
baby’s suckling action at the breast.
Towards the end of a breastfeed baby may reduce nutritive suckling and revert to
non-nutritive sucking as she drifts off the sleep. This normal transition is a legitimate
part of the breastfeed, enabling the milk which is still moving from her throat to her
stomach to be ingested gradually, and the comfort provided by the non-nutritive
sucking enhances relaxation and the transition to sleep8
Here are some practical tips from The Raising Children’s Network 9
for everyday dummy use:
* If you’re breastfeeding, offer the dummy only when you can be sure
your baby isn’t hungry – for example, after or between feeds. This helps to ensure
that dummy-sucking doesn’t interfere with breastfeeding.
* Check the dummy regularly to see whether it’s worn or degraded. Replace the
dummy if it’s broken or worn. Babies can choke on any loose bits.
* Keep spare dummies handy. Your baby is sure to drop the dummy
somewhere without you noticing, then get upset when they want it again.
* Don’t dip the dummy in sweet drinks or sweet food like honey. This can
cause tooth decay.
* Don’t tie the dummy around your baby’s hand, neck or cot. This is
a strangulation risk if the dummy chain or tie is long enough to catch around
your baby’s neck.
Babies under 6 months should use dummies that have been sterilised. There are
several ways to sterilise bottle-feeding equipment, which you can also use to sterilise
dummies. From about 6 months, your child will be more resistant to infections. This
means you need only to wash the dummy with soap and water, rather than sterilising
it. Just make sure to squeeze out any fluid that gets inside. Choose a dummy that
complies with Australian Standard AS 2432:2015
https://www.productsafety.gov.au/product-safety-laws/safety-standards-bans/mandatorystandards/baby-dummies-and-dummy-chains
References:
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462418/
- https://researchoutreach.org/articles/pacifiers-interfere-breastfeeding-success/
- An evaluation of the benefits of non-nutritive sucking for premature infants as
described in the literature. C Hardy Arch Dis Child. 2009 Aug;94(8):636-40. doi:
10.1136/adc.2008.144204. - https://researchoutreach.org/articles/pacifiers-interfere-breastfeeding-success/
- Socio-demographic associations with digit and pacifier sucking at 15 months of age
and possible associations with infant infection. The ALSPAC Study Team. Avon
Longitudinal Study of Pregnancy and Childhood – PubMed (nih.gov) - Tesini, D.A., Hu, L.C., Usui, B.H. et al. Functional comparison of pacifiers using finite
element analysis. BMC Oral Health 22, 49 (2022). https://doi.org/10.1186/s12903-
022-02087-4 - Sanches MT. Clinical management of oral disorders in breastfeeding. J Pediatr (Rio
J) 2004;80(Suppl 5):S155–S162. [PubMed] [Google Scholar] - https://www.NewBaby101.com.au
- https://raisingchildren.net.au
This blog was written by Lois Wattis for Raising Mamas Sunshine Coast Mothers Group and first published in July 2023 https://www.raisingmamas.com.au
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