Pacifier, Soother or 'dummy' use: Benefits and Considerations

A pacifier can be a useful tool for some babies and families. Non-nutritive sucking can provide comfort and regulation, and in some clinical circumstances it may support the development of oral feeding skills. At the same time, prolonged or frequent pacifier use can have potential implications for feeding, oral function and developing orofacial structures.

The question is therefore not whether pacifiers are simply “good” or “bad”. It is about why a pacifier is being used, when it is being offered, how frequently it is used, and whether it is supporting or interfering with what the individual infant needs.

Families deserve balanced information without judgement. A pacifier may be a helpful settling tool for one family while becoming an unhelpful substitute for responsive feeding in another.

For healthcare professionals, conversations about pacifier use are also an opportunity for clinical reasoning. Anatomy provides information; function provides context. A pacifier does not diagnose tongue-tie, explain every feeding difficulty or determine a baby's feeding outcome. It is one part of a much wider picture that includes infant health, gestation, feeding method, feeding effectiveness, weight gain, milk supply where relevant, parental comfort, sleep, family circumstances and individual goals.

What is non-nutritive sucking?

Sucking is an important infant behaviour and does not always have a nutritional purpose. Non-nutritive sucking describes sucking without the transfer of milk and can occur naturally through finger or hand sucking, as well as with a pacifier.

Non-nutritive sucking can have a role in infant regulation and settling. It also involves coordinated activity of the lips, cheeks, tongue and jaw. In premature infants, non-nutritive sucking has been studied as part of supporting the development and progression of oral feeding. Research has reported potential benefits for outcomes such as progression to oral feeding and hospital stay, although the quality and findings of individual studies vary.

This is an important positive aspect of pacifier use. A pacifier is not simply an object that “stops a baby crying”. Sucking is a physiological behaviour with developmental and regulatory functions.

However, the fact that non-nutritive sucking can be beneficial does not mean that more sucking is necessarily better. The context, duration and frequency of use matter.

When can pacifier use become unhelpful?

Pacifier use may become unhelpful when it repeatedly delays or replaces feeding, masks feeding cues, becomes a constant source of soothing, or limits opportunities for other oral experiences.

In the early weeks, frequent feeding is biologically normal. For babies feeding at the breast, milk removal also plays an important role in establishing and maintaining milk production. If a pacifier is repeatedly used to settle a baby who is actually hungry, the feed may be delayed and opportunities for breast stimulation and milk removal may be reduced.

This does not mean that every pacifier use outside a feed is problematic.

A baby who has fed effectively and is then offered a pacifier for comfort is very different from a baby who is repeatedly given a pacifier instead of being offered a feed.

The same principle applies to bottle-fed and combination-fed infants. A bottle or teat can be an entirely appropriate means of providing nutrition. The concern is not that bottle feeding is harmful, but that prolonged sucking on a teat or pacifier beyond nutritional need may become a habitual oral behaviour.

Clinical assessment should therefore consider what the infant is communicating rather than assuming that the pacifier itself is the cause of a feeding difficulty.

Pacifiers and breastfeeding

The relationship between pacifier use and breastfeeding is more complicated than a simple statement that pacifiers “cause breastfeeding problems”.

Observational research has reported associations between pacifier use and shorter breastfeeding duration, but association does not establish causation. In some situations, pacifier use may contribute to reduced feeding opportunities; in others, pacifier use may have been introduced because breastfeeding was already difficult, the baby was unsettled or the family was experiencing feeding challenges.

A Cochrane review of healthy, term infants whose mothers intended to breastfeed found that restricting pacifier use did not significantly increase breastfeeding rates at three or four months compared with unrestricted use. This does not mean that timing and context are irrelevant, particularly when a baby is struggling to transfer milk or when milk supply is being established.

For families establishing breastfeeding, the priority should therefore remain responsive feeding, effective milk transfer, appropriate monitoring of weight and output, and timely support when feeding is difficult.

If a pacifier is being used, families can be encouraged to consider whether it is being offered after an effective feed or whether it is being used to postpone a feed.

This distinction is particularly important when there is already concern about milk transfer, infant weight gain, maternal nipple pain or milk supply.

Where tongue-tie is suspected, a frenulum should not be considered in isolation. Assessment should consider tongue function alongside feeding history, observation and the individual infant's circumstances.

The tongue's resting position

One consideration that is sometimes overlooked is what happens to the tongue while a pacifier is in the mouth.

A pacifier occupies space within the oral cavity and influences where the tongue can rest. Rather than having unrestricted opportunity to adopt a natural resting position within the mouth, the tongue is required to accommodate the pacifier.

Occasional use is unlikely to have the same implications as frequent or prolonged use. However, when a pacifier is present in the mouth for substantial periods of the day, the infant has correspondingly less time experiencing other oral postures and movements.

Research into prolonged pacifier sucking has identified associations with changes in resting tongue position, lip posture, swallowing patterns and the shape of the hard palate. However, the evidence needs to be interpreted cautiously because much of the available research is observational and methodological quality varies.

This is therefore not an argument that pacifiers cause abnormal tongue posture in every infant. It is a reason to consider duration and frequency of use, particularly where there are already concerns about oral function.

Pacifiers, dentition and developing orofacial structures

The developing mouth is responsive to repeated patterns of muscle activity and pressure.

A systematic review examining pacifier sucking and orofacial structures identified associations with anterior open bite and posterior crossbite. However, the authors also found that most of the available studies had serious or moderate risk of bias and concluded that high-level evidence was lacking.

This is an important example of why evidence should not be overstated.

It would be inappropriate to tell a family that using a pacifier will inevitably cause dental problems. Equally, it would be inappropriate to suggest that prolonged sucking habits have no potential effect on developing oral structures.

Duration and frequency appear to be important considerations. The longer and more frequently a sucking habit continues, the greater the opportunity for it to influence developing oral structures.

This principle also applies to prolonged use of feeding teats. Bottle feeding itself should not be presented as harmful, particularly because bottles may be an essential and appropriate means of providing nutrition. The consideration is whether an infant continues to suck habitually on a teat for prolonged periods beyond the nutritional requirements of the feed.

As children grow, reducing prolonged sucking habits can therefore be considered as part of supporting healthy oral development.

Pacifier use following frenulotomy

Pacifier use following frenulotomy is an area where clinical practice and evidence do not always align neatly.

Following a frenulotomy, the wound needs to heal while the newly released tongue is able to move functionally. Some clinicians advise avoiding pacifiers during the healing period because of concerns about the sucking pattern, tongue positioning and the possibility that these could influence wound healing or contribute to re-adhesion.

However, it is important to distinguish clinical reasoning from established evidence.

There is currently no robust evidence demonstrating that pacifier use causes re-adhesion following frenulotomy.

Research into post-frenotomy care remains limited and variable. There is substantial variation in postoperative care practices, and the evidence examining the relationship between postoperative care and outcomes remains limited.

More research is needed to establish whether particular postoperative practices influence wound healing, functional outcomes or re-adhesion.

For this reason, families should be given clear, individualised postoperative advice by the clinician responsible for their baby's care. A pacifier should not automatically be described as causing re-adhesion when the evidence does not establish that relationship.

Pacifiers and SIDS: what does the evidence really tell us?

Pacifier use has been associated with a reduced risk of sudden infant death syndrome (SIDS) in observational research. This association has led to recommendations in some safer-sleep guidance to consider offering a pacifier at sleep times.

However, there is no robust evidence that pacifier use prevents SIDS.

A Cochrane review specifically examining pacifiers for SIDS prevention found no eligible randomised controlled trials and concluded that there was no randomised trial evidence on which to support or refute pacifier use for the prevention of SIDS.

This distinction matters.

An association identified in observational research does not demonstrate that the pacifier itself prevents SIDS. Other factors associated with pacifier use may contribute to the observed relationship.

A pacifier should therefore not be presented to families as a proven protective measure against SIDS.

This is particularly important for babies who are not breastfed. A baby being formula-fed, bottle-fed or combination-fed should not automatically be offered a pacifier because they are not breastfeeding, on the assumption that the pacifier will compensate for the absence of breastfeeding or provide established protection against SIDS.

Breastfeeding itself is associated with a reduced risk of SIDS. This does not mean that families who do not breastfeed should feel blamed, or that a pacifier should never be used. It means that pacifier use should not be presented as a substitute for the protective association associated with breastfeeding.

For a breastfed baby, there is also a practical feeding consideration. If a pacifier is repeatedly used to settle a baby who is hungry, it may delay feeding and reduce opportunities for milk removal. Protecting responsive feeding and effective milk transfer should therefore remain a priority, particularly while breastfeeding is being established.

Safer sleep advice should always be considered as a whole rather than reduced to one intervention or product.

Ear health

Frequent pacifier use has also been associated with an increased risk of acute otitis media.

This does not mean that every infant who uses a pacifier will develop ear infections. However, where a child experiences recurrent middle-ear infections, the frequency and duration of pacifier use may be worth considering as part of a wider clinical picture.

Families should be supported to make gradual changes where appropriate rather than being given blanket advice or made to feel that they have caused their child's ear problems.

When might reducing pacifier use be helpful?

There is no single age at which every baby needs to stop using a pacifier.

Instead, it can be useful to consider the role that the pacifier is playing.

Questions to consider include:

• Is the baby feeding effectively?

• Is the pacifier being used after feeds or to delay feeds?

• Is the baby gaining weight appropriately?

• Are feeding cues being recognised and responded to?

• Is the pacifier being used occasionally or for substantial periods of the day?

• Is it being used primarily for sleep, or throughout waking hours?

• Is the infant developing other ways of settling and regulating?

• Are there concerns about tongue function, oral posture or feeding?

• Is the child experiencing recurrent ear infections?

• Is prolonged sucking continuing as the child develops a primary dentition?

• Has the infant recently undergone a frenulotomy and been given specific postoperative advice?

For some families, reducing pacifier use may be straightforward. For others, it may be an important source of comfort and regulation and need to be reduced gradually.

A family-centred approach recognises both realities.

A balanced approach for families

A pacifier can be useful.

It can support non-nutritive sucking, comfort and regulation, and in particular clinical circumstances non-nutritive sucking may have a role in supporting oral feeding development.

But useful does not mean necessary, and occasional use is different from prolonged habitual use.

The potential concerns relate particularly to what happens when a pacifier becomes a frequent or constant presence: feeds may be delayed, feeding cues may be missed, opportunities for milk removal may be reduced, the tongue's unrestricted resting position may be limited, and prolonged sucking habits may influence developing oral structures.

The evidence around these effects is not equally strong. Some areas have better evidence than others, and some commonly repeated clinical claims remain insufficiently studied.

This is especially important following frenulotomy. Concerns about pacifier use during wound healing may be clinically reasonable, but there is not currently robust evidence demonstrating that pacifier use causes re-adhesion. Families should therefore receive individualised advice rather than absolute statements presented as established fact.

The same balanced approach should be applied to SIDS.

There is no robust evidence that pacifier use prevents SIDS. An observational association should not be transformed into a guarantee of protection, and a baby who is not breastfed does not need a pacifier as a substitute for breastfeeding or as an established SIDS-prevention measure.

Ultimately, the most useful question is not:

> “Are pacifiers good or bad?”

It is:

> “Is this pacifier helping this baby and family, and is anything important being missed?”

That question allows families to make informed decisions without fear, guilt or judgement.

A pacifier can be a useful tool. It can also become unhelpful when its use is prolonged, excessive or substituted for something the infant actually needs.

As with so many aspects of infant feeding and development, context matters.

References

Hauck, F.R., Thompson, J.M.D., Tanabe, K.O., Moon, R.Y. and Vennemann, M.M. (2011) ‘Breastfeeding and reduced risk of sudden infant death syndrome: a meta-analysis’, Pediatrics, 128(1), pp. 103–110. doi: 10.1542/peds.2010-3000.

Jaafar, S.H., Ho, J.J., Jahanfar, S. and Angolkar, M. (2016) ‘Effect of restricted pacifier use in breastfeeding term infants for increasing duration of breastfeeding’, Cochrane Database of Systematic Reviews, 2016(8), CD007202. doi: 10.1002/14651858.CD007202.pub4.

Psaila, K., Foster, J.P., Pulbrook, N. and Jeffery, H.E. (2017) ‘Infant pacifiers for reduction in risk of sudden infant death syndrome’, Cochrane Database of Systematic Reviews, 2017(4), CD011147. doi: 10.1002/14651858.CD011147.pub2.

Schmid, K.M., Kugler, R., Nalabothu, P., Bosch, C. and Verna, C. (2018) ‘The effect of pacifier sucking on orofacial structures: a systematic literature review’, Progress in Orthodontics, 19, 8. doi: 10.1186/s40510-018-0206-4.