How do you answer the question about whether a pacifier is okay for a newborn? Does “baby-friendly” have to mean no pacifiers? There seem to be enough data to make a new parent feel either good or bad about every choice they make, and pacifiers are no exception. However, reviewing the data a little more closely may help refine the guidance we give in those early days and protect the rapport we build with families.
The American Academy of Pediatrics (AAP) policy statement on breast-feeding and the use of human milk that was published in 2012 reiterates their endorsement of the World Health Organization/United Nations Children's Fund (WHO/UNICEF) Ten Steps to Successful Breastfeeding.1 These steps are discrete, helpful, and largely evidence-based in their improvement of establishing exclusive breast-feeding, and they have been incorporated into the Baby-Friendly Hospital designation process.2 Step 9 of the WHO/UNICEF guidelines specifically relates to the use of pacifiers and artificial nipples, stating that compliant hospitals should not give any artificial nipple to a breast-feeding infant outside of a medical procedure or a medical condition. Although pacifiers do not directly cause harm, there are numerous studies concluding that the use of pacifiers prior to establishment of breast-feeding is associated with lower rates of exclusive breast-feeding.3 Given the overwhelming health benefits of breast-feeding for both mother and baby, considerable effort should be made by health care providers who care for mothers and newborns to integrate these recommendations into their clinical practice.
Despite the backing of the WHO/UNICEF steps to successful breast-feeding, the AAP does not support a categorical ban on pacifiers. Pacifier use at naptime and bedtime has been associated with a decreased risk of sudden infant death syndrome (SIDS).4 Apart from choosing breast-feeding and ensuring a safe sleep environment, pacifier use provides parents and pediatricians a straightforward and active behavior that research supports is associated with a lower risk of tragedy. Furthermore, there are obvious reasons why it might be desirable to use a pacifier to appease non-nutritive sucking instincts for self-soothing, such as maternal rest, flexibility, and family preference to avoid digit sucking.
It is not surprising that there remains tension between messaging from staff in the newborn nursery of a hospital maintaining a “Baby-Friendly” designation and that coming from an office-based pediatrician a few weeks later after breast-feeding has been well-established. The juxtaposition of these messages needs to be couched in the acknowledgment that establishing a strong breast-feeding relationship and milk supply typically takes 3 to 4 weeks, although it can occur sooner.1 However, as the Baby-Friendly Initiative organization points out, this is never the case in the first 2 days of life.2
So which comes first: pacifier use or difficulties with breast-feeding? The answer is almost certainly not universal across all mother-baby dyads. One of the only randomized controlled trials attempting to answer this question assessed early weaning within the first 3 months in intervention and control groups that differed only in the recommended avoidance of pacifier use and suggestion of alternative ways to comfort a fussy baby; the intervention was successful at reducing pacifier use but did not affect rates of early weaning.5 Use of a pacifier was noted in observational analyses to be strongly associated with risk of early weaning in both study arms, leading the authors to conclude that pacifier use is a “marker of breast-feeding difficulties or reduced motivation to breastfeed, rather than a true cause of early weaning.”5 Placing a point of emphasis on supporting newly breast-feeding mothers to improve comfort, decrease stress, and promote confidence in establishing effective breast-feeding is probably the more fruitful point of focus for clinicians.
Although elimination of pacifier provision to newborns in the nursery is 1 of the 10 WHO/UNICEF recommendations, research suggests that when these 10 guidelines are not implemented effectively in combination, poorer rates of exclusive breast-feeding may ensue. Most notably, one study discovered that pacifier restriction without explicit formula restriction in the newborn nursery was associated with lower rates of exclusive breast-feeding, higher rates of formula supplementation, and higher rates of exclusive formula-feeding.6 Although the authors of this study caution that their findings demonstrate a temporal association and not necessarily causation, this study serves as a cautionary tale for the pediatrician caring for a mother-baby dyad beyond the nursery, as self-restriction from pacifiers may lead to some parents considering formula for their infant, when they otherwise might not have, unless properly educated and supported with their breast-feeding endeavors.
It is important to point out that there are appropriate, medically indicated reasons to offer a breast-fed newborn formula supplementation outside of a neonatal intensive care unit, such as in the instance of late preterm status, jaundice, dehydration to the point of oliguria, hypernatremia, and hypothermia due to weight loss. However, limiting the volume offered to the minimum needed to prevent harm should not interfere with the periodicity of encounters at the breast, and usually occurs after attempting to feed at the breast. A supplemental nursing system, cup, or spoon method are ways to avoid a bottle nipple, although families may not always find these to be practical approaches.
“Nipple confusion” is an ill-defined phenomenon but one that many parents may bring up in the nursery or at well-child visits. Simply put, the idea is that an infant may develop maladaptive sucking habits after the introduction of an artificial nipple that damages the infant's ability to achieve a latch or let-down at their mother's breast. It is the authors' experience that nipple confusion typically falls into the realm of zealotry—either a parent has strong convictions that it is something that happens or he or she does not. A recent review article nicely points out that there are roughly equivalent numbers of publications that posit a correlation between pacifiers and nipple confusion and those that do not.7 Broadly speaking, infants can develop a nipple preference, but this would not occur until beyond the neonatal neurodevelopmental stage.
There are many ways to have a productive and supportive conversation about pacifier use. Remaining friendly and unassuming, you can acknowledge that pacifiers do not directly cause harm, and when used at sleep time can even reduce the risk of SIDS. However, it is probably prudent to pivot next to asking how breast-feeding is going. Take the time to understand how the latch has felt, how much assistance has been offered with positioning, and what the mother's expectations are of early breast-feeding. Remember, the pacifier may be a symptom of tumult, not the cause. If the frequency of feeds, duration, and quality all seem acceptable, explore the motive for early pacifier introduction. Is it anxiety surrounding perceived infant discomfort? A need for more sleep? A desire to develop a pacifier attachment in anticipation of transition to home or a childcare facility? Or simply a perception that happy babies use a pacifier?
The other way this conversation goes is that a mother discloses she read during pregnancy that pacifiers sabotage breast-feeding and is dismayed to learn her baby was offered one during a painful procedure, such as a blood draw or circumcision. In these moments, it is again more important to acknowledge that the association is far more nuanced and to turn to exploring how breast-feeding is going rather than dwell on the brief pacifier exposure. For the baby already latching well and coming to the breast frequently, a pacifier is unlikely to derail breast-feeding. In fact, there are medical indications for infants to use pacifiers as trainers and surrogates when breast-feeding is not available to them.8 Premature infants, low-birthweight infants, and other tube-fed infants are encouraged to practice non-nutritive sucking in association with feeds to promote coordination and positive feeding behaviors. Infants of mothers with medical conditions preventing breast-feeding may be offered a pacifier to promote sucking and soothing.
As the pediatrician, you are an important voice but not the only voice guiding new parents. In a study of 670 first-time mothers, 79% introduced a pacifier to their newborn, and the most frequent source of advice endorsing the use of a pacifier came from the infant's grandmother.9 Ultimately, the take away message you want a family to hear is that it takes time to establish a strong breast-feeding relationship. Ensuring that parents learn what effective breast-feeding looks and feels like will help empower them to make the best decision for their newborn as it relates to use of a pacifier.
- Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841. doi:10.1542/peds.2011-3552 [CrossRef] PMID:22371471
- Baby-Friendly USA. Interim Guidelines and Evaluation Criteria for Facilities Seeking and Sustaining Baby-Friendly Designation. Albany, NY: Baby-Friendly USA; 2019.
- Buccini GS, Pérez-Escamilla R, Paulino LM, et al. Pacifier use and interruption of exclusive breastfeeding: systematic review and meta-analysis. Matern Child Nutr. 2017;13(3):e12384. doi:10.1111/mcn.12384 [CrossRef]
- Moon RYTask Force On Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5): e20162940. doi:10.1542/peds.2016-2940 [CrossRef] PMID:27940805
- Kramer MS, Barr RG, Dagenais S, et al. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. JAMA. 2001;286(3):322–326. doi:10.1001/jama.286.3.322 [CrossRef] PMID:11466098
- Kair LR, Kenron D, Etheredge K, Jaffe AC, Phillipi CA. Pacifier restriction and exclusive breastfeeding. Pediatrics. 2013;131(4):e1101–e1107. doi:10.1542/peds.2012-2203 [CrossRef] PMID:23509161
- Zimmerman E, Thompson K. Clarifying nipple confusion. J Perinatol. 2015;35(11):895–899. doi:10.1038/jp.2015.83 [CrossRef] PMID:26181720
- Lubbe W, Ten Ham-Baloyi W. When is the use of pacifiers justifiable in the baby-friendly hospital initiative context? A clinician's guide. BMC Pregnancy Childbirth. 2017;17(1):130. doi:10.1186/s12884-017-1306-8PMID:28449646 [CrossRef]
- Mauch CE, Scott JA, Magarey AM, Daniels LA. Predictors of and reasons for pacifier use in first-time mothers: an observational study. BMC Pediatr. 2012;12(7):7. doi:10.1186/1471-2431-12-7 [CrossRef] PMID:22257532