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When my children were infants, I recall not having a pacifier right now as a major parenting fear, perhaps due to the frequency with which I lost them. One result was we had them around everywhere. Even years later, I would occasionally find a lone pacifier in the corner of some unused luggage or a hidden pocket of a jacket. When I said I was going to write about pacifiers, someone messaged to ask if I would please address the question of whether they really needed to change them out every six weeks. The answer is no, although you should watch for rips or other physical damage and dispose of them if you see that. But my first thought in reading the question was What kind of wizard has held on to a pacifier for six weeks?!
My point is, pacifiers are a big deal and also a source of stress. For infants, there seem to be risks to pacifier use (nipple confusion?) but also benefits (SIDS prevention?). And later on, when parents become concerned about when they need to take the pacifier away, there are worries about long-term use.
There are questions in between, too: When do I need to change out pacifiers? Does using a pacifier affect my child’s ears or teeth? And is thumb-sucking okay after all?
So here it is, a deep dive into the world of pacifiers. I’ll take you through all the possible stages of pacifier use and the questions that might arise during those stages. I’ll also touch on popular questions about the impact of pacifiers on language development, ear infections, and teeth.
Concerns about pacifiers for infants and babies
The primary reason parents use pacifiers for infants is to, well, pacify them — to calm them down, have them cry less, etc. A lot of experience suggests this works, and there is randomized trial evidence that pacifiers are helpful during painful procedures like blood draws, for example. Generally, the “soothing” value of the pacifier is well established.
If this were the only consideration with pacifiers, the stress level would be dialed way down. If you want to pacify your kid, use it. If not, don’t. What ups the stress are the two other considerations, which don’t have easy or well-established answers: Should I be afraid of “nipple confusion,” in which a pacifier will make it less likely that I breastfeed successfully? And can pacifiers actually prevent SIDS?
Do pacifiers interfere with breastfeeding success?
I dove into the topic of nipple confusion in Cribsheet. This is a classic example of correlation-is-not-causation. It’s true that infants who use a pacifier are less likely to breastfeed; those things are correlated. However, the relationship does not seem to be causal: in randomized trials, discouraging pacifier use has no impact on breastfeeding. In other words, using a pacifier will not hinder your child’s ability to breastfeed. This has been seen in multiple trials and is summarized in a meta-analysis.
Perhaps my favorite of the individual studies of breastfeeding and pacifier use is this one, which included 281 women in Quebec, randomized into either discouraging or not discouraging pacifier use. The researchers found that pacifier use was less common when it was discouraged but that there was no difference in breastfeeding rates. This is the randomized conclusion, which echoes others: no causal link.
What I like about the paper, though, is that it also compares breastfeeding rates at three months for moms who choose to use a pacifier or not without the randomization. Basically, it looks at the correlations directly, so we can see what’s happening on both sides: correlative and causal, non-randomized and randomized.
The graph below shows the two analyses — the randomized and non-randomized. If you focus only on the non-randomized data, it looks like pacifier use lowers breastfeeding rates. But that’s just a correlation! And we know that because we see the randomized data in the same population.
Conclusion: Pacifiers do not cause nipple confusion or interfere with breastfeeding. They don’t! Stop worrying about this!
Do pacifiers reduce SIDS risk?
On the flip side, you’ll hear that pacifiers can reduce SIDS risk. It is not completely clear what the mechanism would be; it is possible that the sucking activity keeps infants slightly more awake, which may lower the risk of SIDS.
These conclusions are based not on randomized data but on case-control studies (example meta-analysis here). The results are consistent in showing that pacifier use is associated with a lower risk of SIDS (perhaps a 10% reduction), although without randomization, it is challenging to draw very strong conclusions.
Overall, pacifiers in infancy offer some obvious upsides (soothing) and some possible upsides (SIDS reduction) and do not appear to have risks. So they are worth trying! Some babies do not take to them well, and you shouldn’t panic about that either.
Should you replace the pacifier if it falls out of your baby’s mouth while sleeping?
If you use a pacifier, as your child ages, there may come a time when the pacifier starts to fall out of their mouth at night and they cry. A 2-year-old can reach around the crib or bed and find the pacifier again, but a six-month-old often cannot. You may find yourself being called in to put the pacifier back in their mouth many, many times.
How should you deal with this?
First, after four months the highest risk of SIDS has passed, so the value of the pacifier beyond the soothing part has diminished. Second — I’ll go into this more below — at this age, there isn’t any strong reason for your child not to use a pacifier at night. Therefore, what to do about it is entirely up to you.
There are two options.
Option 1: Go in and replace the pacifier when it falls out.
Option 2: Do not go in and replace the pacifier when it falls out.
The second option is, basically, a form of sleep training. If you do this, your baby will cry for a while, and then a couple of days in, they will figure it out. I’ve written before about sleep training in general; this is just a slight variation.
The downside of Option 2 is the crying. The downside of Option 1 is that you might possibly have to do it forever (or at least it might feel that way). Which you choose will probably depend on how often the pacifier actually falls out. If it happens once or twice, it might be manageable for you to replace it. If you find you have to go into your baby’s room 15 times every night, it may be unsustainable.
One important note: If you face this choice, make it thoughtfully and stick to it. As with infant sleep in general, you’ll make your life harder if you swap back and forth between things. Your baby will be confused, it will take longer to get where you want to go, and you’ll be tired. Trust me, and learn from my first baby mistakes.
Concerns about pacifiers in toddlerhood
Many babies who use pacifiers in sleeping drop them after infancy. But this is not true of all babies — pacifier use is actually relatively common among toddlers, through the age of 3, 4, or beyond. Use of pacifiers in this age range is often bundled together with finger- or thumb-sucking as “non-nutritive sucking” behaviors. Are these behaviors risky? If so, why? And what can you do about them?
There are three primary downsides linked to pacifier use: concerns about language development, ear infection risk, and stuff about teeth. (Thumb- and finger-sucking concerns largely focus on the teeth part of this.)
Up-front caveat to everything: nothing below is randomized. Studies here rely on observational data — comparing kids who use pacifiers or suck their thumbs with those who do not. The result is that, at a minimum, we want to think very carefully about what the biases are in the data and, after considering those, what we can learn from it.
Do pacifiers affect language development?
In principle, you can imagine that using a pacifier frequently would impair language development — if a child always has a pacifier in their mouth, they have fewer opportunities to say words. But in practice, the data doesn’t support this concern. Here’s one study, which shows no differences in speech patterns between habitual pacifier users and others. Another showed a slightly elevated risk of “atypical speech errors” but found no other differences, and even this difference appeared only in younger children and is associated only with prolonged daytime use, not nighttime use.
In general, I read from these findings limited reasons to be concerned about language development links to pacifiers.
Do pacifiers increase the risk of ear infections?
Many studies have pointed to pacifier use as a risk factor for ear infections. These aren’t randomized, as noted; instead, they estimate what factors are linked to the development of ear infections in children.
One example is a meta-analysis from 1996, which looks at the links between ear infections and many different variables. Pacifier use was associated with a slightly increased risk of ear infections, though not nearly as strongly associated as day care outside the home, family history of ear infections, or parental smoking. Other studies echo these basic patterns.
These citations are fairly old, and the way we treat ear infections has changed somewhat. A more recent study, from 2008, shows a very moderate and not significant increase in ear infections associated with pacifier use (32% of children who do not use a pacifier developed an ear infection over four years, versus 35% with a pacifier). All together, this suggests a small, plausible but not certain link between pacifier use and ear infections. The fact is, a lot of kids get an ear infection even without using a pacifier. Using one could increase it a little, but it probably matters much, much less than other factors like basic underlying predisposition.
How do pacifiers affect teeth?
The main concern about pacifier use (and thumb- or finger-sucking) is the effect on teeth. This is certainly the area with the most data.
There are many studies, going back to at least the 1970s, showing links between pacifier use and “malocclusion” (crooked teeth). Pacifier use, as well as finger- and thumb-sucking, are associated with various teeth issues (overbite, overjet, etc.). One study, for example, followed 80 mother-infant pairs, collected data on their pacifier use, and measured dental features up through 30 months. It found pacifier use and finger-sucking associated with various dental issues through 30 months.
Among the larger studies is one in Hong Kong that collected data on 1,114 children ages 2 through 5 and, again, found a link between pacifier and finger-/thumb-sucking and dental issues (overbite, open bite, etc.). And a review from 2016 argues for consistent links between both pacifier- and finger-sucking and dental issues in the primary (i.e. baby) teeth. In the 2016 review, pacifier use had an even higher risk of damaging teeth than finger-sucking.
Although there is a fair amount of evidence, the quality of it isn’t airtight. A 2018 review concluded with: “High level of evidence of the effect of sucking habits on orofacial structures is missing.” In other words, the evidence that it found in either direction wasn’t very good.
Part of the reason teeth damage is considered the most likely consequence of pacifier usage or thumb-sucking is that it makes sense mechanically. It isn’t surprising to think that sucking on something that puts pressure on your teeth would change the shape of the mouth.
Should you cut out pacifier use or thumb-sucking? (And if so, how?)
Ultimately, it’s a mixed bag. Ongoing pacifier use or finger-sucking seems to have some impact on teeth shape. How important this impact is — how you weigh it against the fact that your child likes the pacifier — seems ambiguous to me. Your child may be more likely to need braces as a result, but they also may well need them anyway.
Should you get rid of the pacifier, though? Is it necessary? On one hand: at some point, most kids do give it up on their own. Peer pressure from friends, general aging — even without intervention, your 6-year-old is not likely to continue to want a pacifier. So you could just wait. On the other hand, the concerns about pacifier use and teeth are much more significantly cited with ongoing use, that is, past two or three years (some citations even suggest the long-term effects appear only after four years). This means that worrying that your 13-month-old is still using a pacifier is unnecessary.
If you find yourself with an older child with a pacifier, however, or with a child who sucks their thumb, what can you do about it? The answer actually differs a bit between pacifier and fingers.
Pacifiers
In the case of pacifiers, I could find no particular studies on how to get kids to quit. I suspect this is because the only real intervention is to take it away. This method will work if you stick with it, although it will make your child unhappy. In this way, encouraging your child to part ways with their pacifier is not dissimilar to encouraging various other changes in behavior in toddlers and young children. You probably do not want to quit cold turkey with no warning, and there are softer, common-sense approaches to be able to get what you want (limit pacifier use to certain areas of the house, use a reward chart, get a gift to replace it, etc.).
Finger- and thumb-sucking
Finger- and thumb-sucking are more complicated. For one thing, they do sometimes persist longer. And for another, you cannot take away the fingers. As a result, there is slightly more evidence on interventions to limit it, though the evidence is generally of fairly poor quality. It shows some moderate impact of both positive and negative reinforcement and of physical interventions like a palatal expander. This is a metal brace that is inserted in the mouth to make thumb-sucking less comfortable, and it will be a last resort for most people.
This feels a bit like the situation where your child refuses to poop on the toilet. You just have to muddle through and hope you eventually hit on a reward/consequence/encouragement/bribe strategy that works.
The bottom line
- Pacifiers in infancy do not cause nipple confusion. They might have a small positive impact on SIDS rates, and they pacify your child. Recommend!
- As your baby gets a little older, when the pacifier falls out of your child’s mouth while they are sleeping, it can be replaced or not. What’s important is that you make a choice and stick with it — your baby will get used to whatever you decide.
- Pacifiers in toddlerhood, especially when continued over a long period of time, may have some negative impacts on dental structures. Thumb- or finger-sucking also has impacts on dental structures. These impacts should be balanced against benefits (kids like their pacifiers/thumbs).
- Pacifier use in toddlerhood has no impact on language development and very little impact on ear infections.
- There is no magic wand for getting kids to give up pacifiers or thumbs. If it’s important to you that your child stops using a pacifier or sucking their thumb, find the bribe that works.
