Your Ultimate Guide to Pacifiers

Most parents these days utilize pacifiers for their infants, but there is a lot of information floating around about when to introduce them, what type to use, and how to best utilize them. For new parents, sorting through all this info can be overwhelming. Let's break down some of the most common questions about pacifier introduction so that you feel educated and can make the decisions that makes the most sense for you and your baby!

What are the benefits of pacifiers?

Particularly beneficial for preterm infants.

Much of the research done in regards to the benefits of pacifier use are related to preterm infants. Pacifiers seem to be especially beneficial for preterm infants for decreasing length of hospital stay, improving bottle feeding skills, and speeding up the transition from enteral feeding to bottle feeding.¹

Comforting effects due to non-nutritive suck.

Non-nutritive sucking is part of a newborn reflex that is triggered by providing a stimulus in or around baby’s mouth, causing them to instinctively open their mouth and suck on an object–the breast nipple, their hands, a pacifier, etc. It’s considered normal in newborns and begins to develop in utero. This action of sucking doesn’t offer any nutritional benefit, but satisfies a psychological need by promoting feelings of security and allowing baby to practice self-soothing. Non-nutritive suck from pacifiers has also been shown to decrease the pain response in infants undergoing painful procedures.^_2,3

Reduction in risk of SIDS.

Since the 1990’s, there has been strong and consistent evidence to support that pacifier use during sleep can decrease the risk of SIDS (Sudden Infant Death Syndrome).^4,5 Understandably, it would be difficult and in many cases unethical to attempt experimental studies on babies related to SIDS prevention, so the nature of the types of studies done on pacifier use and its effect on SIDS makes them largely unable to point to any specific reason for these findings or determine a cause and effect relationship. This means that yes, SIDS risk is reduced when pacifiers are used, but we aren’t totally sure why. 

Because of the established risk reduction in SIDS with pacifier use, the AAP recommends introducing a pacifier for nap and nighttime.⁶ But you don’t need to feel like you have to force it on your baby. If they don’t take a pacifier, it’s not necessary to push it on them. Breastfeeding, especially exclusive breastfeeding, has also been found to greatly reduce the risk of SIDS.⁷ Regardless, always put your baby to sleep in a safe sleep environment.

What are the risks of pacifiers?

There is a potential for disruption in exclusive breastfeeding, but the overall evidence is conflicting.

Pacifier use has often been discouraged among breastfeeding mothers due to evidence suggesting that pacifier use decreases rates of exclusive breastfeeding.^8,9 However, there is conflicting data in this area, with other studies suggesting that pacifier use may actually be a marker of breastfeeding difficulties or reduced motivation to breastfeed rather than a true cause of early weaning.¹⁰ A recent review found that pacifier use in healthy, term, breastfeeding infants, started from birth or after lactation is established, did not significantly affect the prevalence or duration of exclusive and partial breastfeeding up to four months of age.¹¹ The authors of this study did note that there is insufficient research exploring how pacifiers may harm infants or how they impact breastfeeding difficulties. So ultimately, it’s up to you to decide, after learning about the risks and benefits, if using a pacifier makes sense for you and your family.

Nipple confusion from pacifiers is a possible but unlikely cause of breastfeeding problems.

Another warning parents often receive related to pacifier use is the risk of nipple confusion. Broadly defined, nipple confusion refers to a difficulty feeding or preference for an artificial nipple after exposure to bottles or pacifiers. There tends to be a divide among professionals regarding the impact or even existence of nipple confusion. A review of recent studies found that the current evidence shows that pacifier-related nipple confusion is unlikely.¹²

Increased risk of ear infections, particularly when used in the second six months of baby's life.

Studies have shown that ear infections are more likely in children that use pacifiers.^13,14 The reason for this is not well understood, though a common theory is that it is due to a pressure change in the inner ear while sucking. The increased risk for ear infection seems to be proportional to the duration and frequency of pacifier use, therefore the AAP recommends reducing or stopping pacifier use in the second six months of life.  Exclusive breastfeeding has been shown to decrease the risk of acute otitis media.¹⁵

Potential for dental problems, especially with prolonged use.

The American Academy of Pediatric Dentistry (AAPD) supports parents in their decision to use a pacifier, noting the potential positives for infant soothing, reduction in risk of SIDS, as well as decreasing the likelihood of thumb or finger sucking, which can be a difficult habit to break, especially in older children. They do note in their policy statement, however, that “pacifier use beyond 18 months can influence the developing orofacial complex, leading to anterior open bite, posterior crossbite, and Class II malocclusion.”¹⁶ Simply put, prolonged pacifier use increases the risk for dental problems in children. 

When should I introduce a pacifier?

The right time to introduce a pacifier depends on your feeding situation.

There is no specific time frame that is recommended for introducing a pacifier, so it can vary based on individual circumstances. For infants not feeding directly at the breast, you can introduce a pacifier whenever you’d like. If planning to breastfeed, it’s usually best to hold off on pacifier use until breastfeeding is well-established and your baby has a consistently good latch–typically around 2-6 weeks. When we say “well-established,” we typically mean:

Prioritize feeding cues and successful latching, then introduce the pacifier when ready.

Frequent, on-demand breastfeeding is hugely important for breastfeeding success, especially related to building up a milk supply during those early days and weeks. Introducing a pacifier too early has the potential to mask problems with breastfeeding, or the pacifier may be used to soothe a hungry baby and displace needed calories. Waiting on pacifier introduction allows you time to get to know your baby’s feeding cues and feeding patterns as well as establish a good latch, and it gives your body time to adjust and maintain a sufficient milk supply. With that said, a recent study comparing early versus late pacifier introduction showed that there was no difference in breastfeeding rates or problems between the two groups.¹⁷ In my personal and professional experience, I have seen pacifiers introduced early on without negative effects on breastfeeding success, as long as you are intentional about when and how you use them. 

How do I introduce a pacifier?

Offer it by gently touching it to baby’s lips, then allow them to open their mouth and latch. Avoid putting it in baby’s mouth without their active participation. If they are not interested, don't force it. Continue to offer it without pressure. 

If they are not interested, you can try: 

• Offering at different levels of alertness and/or different times of day, especially at night when more drowsy. 
• Dipping the pacifier tip in breast milk or formula to incentivize them. _{(Don't use sugar water or other liquids to incentivize infants to take a pacifier. This is still occasionally recommend by well-meaning friends or family members but is not a research-based practice.)}
• Try rocking, bouncing or other gentle movement while offering it.

What's the best type of pacifier?

There is no one best type or brand, but aim for an ideal shape to promote optimal sucking habits.

Our main goal when choosing a pacifier is to find one that supports an ideal sucking pattern. This is especially important for breastfed babies to avoid creating bad habits that may negatively impact their latch at the breast.

When a baby is actively nursing, the breast nipple is stretched far back into their mouth. Look for a pacifier with similar qualities to the breast nipple during active sucking, including:

Conventional or orthodontic, they can still impact the palate's shape. 

There are conflicting opinions in the medical, dental, and lactation fields related to the ideal pacifier shape. Pacifiers are usually categorized as conventional or orthodontic, but there is a huge variation from brand to brand in terms of their overall shape and design, so there is no conclusive recommendation as to the “best” type of pacifier.

Studies have shown that pacifiers affect the palate differently based on size and design, regardless of whether they are labeled conventional or orthodontic.

Avoid orthodontic or bulb-shaped pacifiers to protect breastfeeding success.

I recommend avoiding orthodontic or bulb-shaped pacifiers for better breastfeeding success. The large tip of a bulb-shaped pacifier limits the tongue movement and cupping that we look for in an ideal sucking pattern. Similarly, orthodontic pacifiers don’t allow for tongue cupping and are also often very short, causing the baby to chomp on the pacifier at the front of their mouth. You can find a link to my most recommended pacifiers below! 

Not every pacifier is right for every baby. Choose the best one for your specific child.

Keep in mind that most research has shown that the negative effects we see from pacifiers such as ear infections and dental problems tend to increase in correlation with increased frequency and duration of use, so don't get too caught up in choosing the "right" pacifier.

If your baby uses a pacifier that doesn’t necessarily check all of the boxes, but they’re still feeding well, there’s no need to stress about it. Keep doing what works! If you're having feeding problems while currently using a non-ideal shape, I suggest trying one with a preferred shape.

Shop my favorite pacifiers here!

Pacifier Safety Tips:

• Pacifiers that are made of just a single piece are less likely to break apart and become a choking hazard.
• The AAP recommends that the shield between the nipple and the ring should be at least 1 1/2” across so baby cannot put the entire pacifier into their mouth. In addition, the shield should be made of firm plastic with ventilation holes.
• The U.S. Consumer Product Safety Commission prohibits straps, cords, or attachments that could pose a danger to infants.
• Regularly inspect your pacifiers for deterioration or damage, and replace as needed. 
• Frequent washing and sterilization is also recommended, as bacteria and fungi have been known to grow on pacifiers if not properly cleaned. 

There are many factors to consider when choosing a pacifier for your baby, and it's easy to over-complicate it with all the different options and advice available to new parents. Hopefully you can use this info to make an informed decision and feel confident that it's the best choice for you and your baby!

If you have more questions or you're having other concerns with feeding your baby, my Bottle and Breastfeeding Course is right for you. Click the link below to find out more!

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<sub>¹ Foster, Jann P., Kim Psaila, and Tiffany Patterson. "Non‐nutritive sucking for increasing physiologic stability and nutrition in preterm infants." Cochrane Database of Systematic Reviews 10 (2016).

² Carbajal, R., et al. "Randomised trial of analgesic effects of sucrose, glucose, and pacifiers in term neonates." Bmj 319.7222 (1999): 1393-1397.

³ Mathai, Sheila, Nisha Natrajan, and N. R. Rajalakshmi. "A comparative study of non-pharmacological methods to reduce pain in neonates." Indian pediatrics 43.12 (2006): 1070.

⁴ Hauck, Fern R., Olanrewaju O. Omojokun, and Mir S. Siadaty. "Do pacifiers reduce the risk of sudden infant death syndrome? A meta-analysis." Pediatrics 116.5 (2005): e716-e723.

⁵ Mitchell, E. A., Peter S. Blair, and Monique P. L’Hoir. "Should pacifiers be recommended to prevent sudden infant death syndrome?." Pediatrics 117.5 (2006): 1755-1758.

⁶ Moon, Rachel Y. “How to Keep Your Sleeping Baby Safe: Aap Policy Explained.” HealthyChildren.Org, American Academy of Pediatrics, 25 Oct. 2023, www.healthychildren.org/English/ages-stages/baby/sleep/Pages/a-parents-guide-to-safe-sleep.aspx.

⁷ Hauck, Fern R., et al. "Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis." Pediatrics 128.1 (2011): 103-110.

⁸ Buccini, Gabriela dos Santos, et al. "Pacifier use and interruption of exclusive breastfeeding: Systematic review and meta‐analysis." Maternal & Child Nutrition 13.3 (2017): e12384.

⁹ Freitas, Camila Nobre de, et al. "Mechanical stress distribution over the palate by different pacifiers assessed by finite element analysis and clinical data." Clinical Anatomy (2023).

¹⁰ Kramer, Michael S., et al. "Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial." Jama 286.3 (2001): 322-326.

¹¹ Jaafar, Sharifah Halimah, et al. "Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding." Cochrane Database of Systematic Reviews 8 (2016).

¹² Zimmerman, E., and K. Thompson. "Clarifying nipple confusion." Journal of Perinatology 35.11 (2015): 895-899.

¹³ Salah, Mohamed, et al. "Recurrent acute otitis media in infants: analysis of risk factors." International journal of pediatric otorhinolaryngology 77.10 (2013): 1665-1669.

¹⁴ Warren, John J., et al. "Pacifier use and the occurrence of otitis media in the first year of life." Pediatric dentistry 23.2 (2001): 103-108.

¹⁵ Uhari, Matti, Kerttu Mäntysaari, and Marjo Niemelä. "Meta-analytic review of the risk factors for acute otitis media." Clinical Infectious Diseases 22.6 (1996): 1079-1083.

¹⁶ American Academy of Pediatric Dentistry. “Policy on Pacifiers.” The Reference Manual of Pediatric Dentistry (2022): 77-80.

¹⁷ Hermanson, Åsa, and Lotta Lindh Åstrand. "The effects of early pacifier use on breastfeeding: A randomised controlled trial." Women and Birth 33.5 (2020): e473-e482.

¹⁸ Tesini, David A., et al. "Functional comparison of pacifiers using finite element analysis." BMC Oral Health 22.1 (2022): 49.</sub>