To give or not to give…that is the question!
Every lactation consultant has been asked, “Is it okay for me to give my baby a pacifier?” A simple question, yet one that is very polarizing in the breastfeeding community. Some lactation consultants will tell you, “Absolutely not. Pacifiers are the worst!” Some are more open to pacifiers in select cases, and still, others say, “Sure. Why not? Do whatever works for you.” But where is the evidence-based information about pacifier use? What are the pros? What are the cons? When should you give the pacifier? Which pacifier should be used? When should it be stopped?
Whether or not to give a pacifier is your decision as new parents. Some babies would not survive without one, while others never take to them. Parenthood is a long line of decisions so being confident in what you select for your family is important. This article addresses commonly asked questions among new parents on the use of a pacifier for a breastfeeding baby and compiles expert opinions from global boards like the World Health Organization, as well as the practical opinions of active, certified lactation consultants.
Frequently Asked Questions About Pacifier Use:
Is there evidence to support the use of the pacifier in a breastfed baby?
The short answer is no, but there is a big “however” attached. Historically, pacifiers were called “dummies”, meaning they can be used in place of the real deal. When a baby was looking for a nipple, these soft plastic replacements could be used for sucking or comfort. If a pacifier is used to replace a nipple for a breastfeeding baby, it will challenge breastfeeding. When babies are looking for the breast, the best practice is to supply it on demand. It is the best way to establish a deep latch and robust breast milk supply. That being said, pacifiers can absolutely be used appropriately with breastfed infants. First, a consistent good latch should be achieved. With full-term infants, make sure you establish positive feeding habits before introducing artificial nipples. Make sure they are well-latched and transferring milk well. This can be assessed via growth at the pediatrician or with a weighted feed. Good milk supply should also be a consideration for the introduction of the pacifier. If you are struggling with supply, any stimulation at the breast can help, so always offer the nipple, not the “dummy”. Once your baby is latching well, transferring milk appropriately, and supply is not of concern, judicious pacifier use should not disrupt exclusive breastfeeding, and the research supports this. In fact, the World Health Organization found that in the full term infant restricted pacifier use had no significant difference in the duration of any breastfeeding in women up to four months postpartum. Another randomized control study done by Kramer, et al. concluded that pacifier use may be a marker of breastfeeding difficulties or reduced motivation to breastfeed, rather than a true cause of early weaning.
The key to all this is determining what is appropriate, judicious, or restricted use. Typically, it means that you do not use the pacifier as a replacement for time at the breast or to space out feedings and that it is used sparingly for comfort sucking only. This usually will not be in the early days of a breastfeeding journey, but at least a couple of weeks in. You will need to learn your baby's hunger cues, their noises, and signals, and figure out the signs that they are full and not interested in eating more. Some babies like to suck for comfort more than others. Some have fussier times of the day when they are not hungry but will soothe with a pacifier. Some fall asleep better with something to suck on. These can all be times when a pacifier is used appropriately. The key is to always ask yourself if the pacifier use is replacing time at the breast. If it is, swap that dummy for a breast!
When is the right time to start using a pacifier?
When you review the recommendations from experts and the evidence in literature, most sources recommend delaying pacifier use until after 4 weeks of age or not using it in the newborn period, but delaying to infanthood. At that time, restricted or judicious pacifier use is recommended. The reasoning for this is it allows time to work out the kinks of breastfeeding, establish a good latch, and get on a proper growth trajectory supported by adequate milk transfer. Once those are established, if you want to introduce the pacifier it should be appropriate or restricted use only. The pacifier should not be used to space out on-demand feeds or sleep train a baby. The pacifier is never a replacement for feeding at the breast. With the introduction of the pacifier, close attention should be paid to feeding patterns and supply, making sure to not jeopardize breastmilk supply or time at the breast with pacifier use. There are a lot of apps out there that can help you keep track of feedings and time at the breast. Many will also have a place to store information about when you introduce a pacifier (if you choose to), and how often you are using it.
Which pacifier should I use?
Wondering what are the best pacifiers for breastfeeding babies? Usually, your baby will help you to answer this question because often they will prefer one type or brand over another. The first pacifier offered should be store-bought, sterilized properly, and for the appropriate age of your baby. The most common first pacifier is what I fondly refer to as the “hospital pacifier” because they are the ones most commonly provided by hospitals to new babies or used in the NICU. Philips AVENT soothie for 0-3 months is the most common and readily available. However, anything that is of an appropriate size for your baby (this is typically marked with an age range on the packaging) is fine to try. You may also want to ask your pediatrician or dentist if they have further recommendations on brand or type as they may have preferences that are not specific to breastfeeding, knowing your baby. As far as breastfeeding babies are concerned, the type of pacifier is not implicated in change or reduction of breastfeeding rates. In most cases, the "right pacifier" is whichever kind your baby enjoys.
Does pacifier use reduce the risk of SIDS in breastfed babies?
Sudden infant death syndrome, also known as SIDS or crib death, is when a baby dies in their sleep. The cause is unknown, though it could be a defect in the portion of the baby’s brain that controls breathing and arousal from sleep. It is devastating to families, especially since there is no known cause or answer. There are a few things that we do know can help to reduce the rates. These include breastfeeding (yay!), putting infants on their backs to sleep, safe sleep surfaces-firm without extra blankets, pillows, etc., not bedsharing, routine immunizations, non-smoking home environment, and use of pacifiers!
As you may have guessed since we do not know why it occurs, we also do not have an answer as to why pacifier use reduces the risk of sudden infant death syndrome. Most likely the sucking affects the respiratory centers in the brain and works as a little reminder to keep breathing while in use. That being said, any pacifier mom knows that it regularly falls out of their baby's mouth while they sleep or once the baby is in a deep sleep so this does not completely make sense. Either way, it is something worth considering as a positive effect of pacifier use when you are deciding on whether or not to offer the pacifier.
What are the cons of pacifier use?
Many breastfeeding resources will vilify the pacifier. It has been called or referenced as the enemy of exclusive breastfeeding, and with inappropriate use it can disrupt the breastfeeding dyad, harming their success. Sucking on a pacifier can trick the CCK system. CCK or cholecystokinin rises when a baby sucks or feeds, making the baby sleepy and telling them that they are full. Within 20 minutes of sucking, it is high enough for the baby to fall asleep, but a baby that is not full from a feed will wake up again after that sucking more hungry. If you continue to trick the CCK system and the baby continues to sleep due to pacifier sucking, the baby can miss out on a feed. The breast will miss an emptying impacting supply and the baby will miss out on nutrition for weight gain. Therefore, offering a nipple for sucking instead of a pacifier is best. Unrestricted pacifier use, using the pacifier to prolong time between feeds, or to put a potentially hungry baby to sleep, can negatively affect breastfeeding.
The concept of nipple confusion is also often discussed as a concern with pacifier use. Any artificial nipple, be it a pacifier or bottle teet, can reinforce bad latch habits. Therefore, if you are struggling with latch it may be best to delay pacifier use. Babies are smart. Most have no problem transitioning from breast nipple, to bottle, to pacifier, and back again, regardless of the different nipple shape. The risk of nipple confusion is that the bottle and pacifier are easier for a newborn to suck on. If a pacifier is regularly used early on before a deep latch is both established and consistent, it can pose a threat or cause some confusion at the breast. This can lead to low supply and poor transfer, which could progress to weight loss and early weaning.
Some people also have a very hard time stopping a regular pacifier habit once it is formed. You may not know yet, but toddlers can be very persistent, and ridding them of one of their favorite things can be difficult. There are lots of tricks and tips out there on how to do it and the timing should be child-specific as discussed with your pediatric provider or dentist. That being said, the easiest way to kick a bad habit is to never start. So some families opt to not start due to the potential difficulties that weaning from a pacifier may bring.
Finally, though not terribly expensive, pacifiers do cost money. If your child does take to the pacifier, you will often need to buy several and continue to buy them as they wear out or the child grows. They are technically an unnecessary expense. Babies do not need them for healthy growth and development. When you have a baby, the expenses can be intimidating, so you may opt to forego the pacifier for this reason as well.
When should I stop using the pacifier?
It is safe to say that if your baby does take to a pacifier, they will definitely have opinions on this one. As a certified lactation consultant, as long as you are using it judiciously and meeting your breastfeeding goals, I do not have a strong recommendation for pacifier discontinuation timing. Your pediatrician and pediatric dentist will likely have opinions based on speech development and dentition/orthodontia. It is also important to make sure as they get older and more mobile that the pacifier is still in working condition and that they are not using their little teeth to chew or put holes it, as that may present a choking hazard. Typically, pediatricians recommend getting rid of the bottle nipples at 1 year. Most dentists state that 3 years of age is an absolute hard stop with pacifier use, but again, if you choose to use your family will have to decide what is best for them.
What is proper pacifier care?
Make sure to read the directions on the pacifier packaging. It will tell you the proper way to prep the pacifier for use and how to sterilize it. If the pacifier is dropped or dirty, it should be washed with warm soap and water. Consider sterilizing at regular intervals based on your use. If the pacifier is ever visibly damaged it should not be given to the baby. Once they get teeth babies often bite on pacifiers damaging the plastic which can be a choking hazard. Even with little cracks or rips in the plastic pacifiers should be replaced. Luckily, they are easily obtained at most stores with baby supplies (Walmart, Target, Amazon, etc.)
Expert Opinions on the Use of Pacifiers:
American Academy of Pediatrics: The AAP recommends weaning children from pacifiers in the second six months of life to prevent otitis media (ear infections). Pacifier use should not be actively discouraged and may be especially beneficial in the first six months of life.
American Academy of Pediatric Dentistry: The AAPD encourages healthcare providers to follow evidence-based literature to educate parents about the safe practices, benefits, and risks of pacifier use by infants and children in order to promote healthy growth and development. The AAPD supports parents in the decision to introduce a pacifier based on their baby’s needs and parental preference, though they encourage weaning by 12 months and pose concerns for orofacial development with use past 18 months of age.
Academy of Breastfeeding Medicine: Recognizes pacifier use is commonly recommended to prevent sudden infant death syndrome. They discourage use until breastfeeding is well established, at least 3-4 weeks post-delivery.
World Health Organization: WHO strongly discourages the use of pacifiers in breastfed children (WHO, 2008).
International Board Certified Lactation Consultant (and Women's Health Nurse Practitioner): The decision to introduce a pacifier should be made based on the needs of each family and considered case by case in each baby. If pacifier use is elected it should be done in a judicious or restricted manner in the exclusively breastfed infant. Deep latch, appropriate milk transfer, and adequate supply should be established first.
International Board Certified Lactation Consultant (and Pediatric Nurse Practitioner): Newborns need to feed frequently early on to establish mom’s milk supply and gain weight. A pacifier may interfere with both by soothing the infant non-nutritively at a time they need to be eating. Early on, it can also reinforce bad habits at the breast by encouraging a narrow latch. Infants vary widely in their need for soothing. Many families may eventually find a pacifier useful for this but should wait until breastfeeding is well established. As infants get older limit pacifier use to nap time, bedtime, and times of stress. At other times, keep it out of sight. If a pacifier is used all the time, it can interfere with speech development.
Whew! What a lot of information about the use of the pacifier. Overall, I hope you take away that the use of a pacifier should not make or break your breastfeeding experience. Establishing a deep latch with appropriate milk transfer is the most important first goal of breastfeeding, so once you have that down, pacifier use is absolutely up to you. You got this, modern mama! Feel confident in your journey.
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